Failure to Implement and Follow Abuse Prevention and Reporting Policies
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, for multiple residents reviewed for abuse policies. Specifically, the facility did not report incidents of resident-to-resident abuse within the required 2-hour timeframe, as outlined in their own policy. Several incidents were not reported to the state agency until days after they occurred, and in some cases, were not reported at all. Additionally, the facility did not gather required written statements for these incidents, nor did they complete the State Provider Investigation Report (5-day report) as mandated by their policy. The report details several incidents involving residents with significant cognitive impairments and behavioral health diagnoses, such as Alzheimer's disease, dementia, bipolar disorder, and psychotic disorders. In one instance, a resident was hit in the back by another resident, and in another, a resident was punched in the face, resulting in a non-displaced nose fracture. There were also incidents where residents were scratched, pushed, or otherwise physically harmed by other residents, leading to injuries such as skin tears and a vertebral compression fracture. Despite these events, the facility failed to follow its own procedures for documentation, investigation, and timely reporting. Interviews with staff and administration revealed a lack of understanding and adherence to the facility's abuse reporting policy. The Administrator was unaware of the 2-hour reporting requirement and did not know about the necessary forms and investigation timelines. Other staff members described notifying supervisors but did not consistently follow through with required documentation or reporting. The facility also failed to analyze these occurrences to determine if changes to policies and procedures were needed and did not refer all incidents to the QAPI committee for further review, as required by their own policy.
Removal Plan
- Residents had interventions put in place including separation from other residents when resident to resident altercations occurred.
- Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient.
- Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behavior were noted.
- Resident #2 & Resident #1 were separated from one another and both sent to ER, while in ER staff made referral to inpatient behavioral hospital. Both Residents #2 & #1 were admitted to inpatient behavioral hospital.
- Abuse reportable events policy was reviewed and revised to include steps for reporting, documentation required and time to report events.
- Abuse/neglect in-services were started with all staff by the Administrator, the DON, nurse managers and department supervisors; all employees must be educated before working their scheduled shift.
- Social Services in-serviced Administrator to complete safety surveys with each incident, especially any allegations of abuse/neglect, to ensure residents feel safe in the facility and they have not experienced any negative events.
- The DON and Nurse manager assigned to educate nurses on documentation related to incidents, including incident reports, witness statements, progress notes, monitoring logs and head to toe skin assessments.
- Per facility policy, charge nurse will be the staff member that begins taking written statements after the allegation is reported to the Administrator and DON.
- Safety surveys started by department heads for residents that could answer survey questions; secured unit charge nurse contacting family members for residents on the secured unit with impaired cognition.
- Resident council meeting scheduled for residents to discuss revision to policy including the steps to reporting and the required documentation that was needed for completing an investigation related to an incident that occurred and was a reportable event.
- Department heads would speak to residents individually that did not attend the meeting and call family members with residents that have impaired cognition. The Administrator would be completing the meeting with residents.
- The Regional director of operations in-serviced the DON and Administrator on revision to policy on abuse/neglect allegations. Policy now has specific contact information with multiple methods of notification including email, phone, and TULIP. Multiple methods on how to submit 3613 investigation report including email, TULIP, and fax.
- Regional Director of operations visited the facility on a monthly basis and would follow up with the Administrator/DON with each self-report to ensure the investigation of self-reports were completed in timely manner and 3613 was submitted to state with all the documentation gathered with investigation. All communication between monthly visits were to be sent through email.
- The Nurse manager started in-service with nurses to discuss documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in-services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that was required for investigation. In-service was related to having more thorough assessment and appropriate documentation in place. In-services would be completed before staff worked the next shift.
- The facility's Abuse Reportable events Policy was reviewed and revised to clarify timelines for internal/external reporting and investigation steps. The revised policy was approved by the Governing Body and redistributed to all departments.
- Future new hires will receive abuse prevention and reporting training during orientation before working any shift.
- The DON or designee will initiate and complete all abuse investigations using the state-approved Form 3613-A process.
- All investigations will be reviewed and signed by the Administrator for accuracy and timeliness before submission.
- The Administrator or DON will audit all incident reports weekly to ensure proper reporting, investigation, and documentation.
- Results will be presented to the QA Committee monthly for review and any needed corrective actions.
- The QA Committee will evaluate compliance and determine if further education or policy revisions are needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse: A resident with schizoaffective disorder and aggressive behaviors threatened and spit on another resident, but staff did not recognize the conduct as abuse, did not report it to the Ombudsman, police, or CDPH, and did not complete the required monitoring documentation. The same resident was later placed in a room with a bedbound resident and allegedly struck that resident with an overhead table, causing a head laceration and hospital transfer. The DON and an LVN stated spitting was not abuse, while the record showed the facility’s policies required abuse identification, investigation, and reporting.
Failure to complete required background check before direct care: CNA 1 was hired and began providing direct resident care before the facility completed the required criminal background clearance. The DON stated background checks were supposed to be done before staff started work, but CNA 1 worked full time and provided direct care for months before the background check was requested and completed. The facility policy required employee background checks as part of its abuse prevention program.
Failure to Report and Investigate Abuse Allegations: The DON, ADON, and Administrator did not treat a resident’s reported fight with a CNA and a separate resident-to-resident assault as reportable abuse events. Records showed conflicting resident statements, visible injuries, and staff accounts describing physical aggression, yet the incidents were not promptly reported to State agencies under the facility’s abuse policy. The Administrator stated the events were not considered abuse because of the residents’ statements and lack of willful intent.
Failure to Investigate and Report Abuse-Related Allegations: The facility did not follow its abuse prevention policy for three residents with abuse-related concerns. One resident reported being called a racial slur by a roommate, another reported degrading and dismissive treatment by a CNA, and a third reported humiliating comments during wound care. Staff and leadership were aware of the concerns, but the facility did not document State reporting, complete abuse investigations, or show resident, staff, or witness interviews, record review, findings, or final decisions.
Abuse Allegation Not Thoroughly Investigated: A resident with moderate cognitive impairment and multiple medical conditions was involved in a transfer incident in which staff described her legs as rigid and locked. Witnesses and the resident reported that an LPN hit or smacked the resident’s leg while telling her to relax and bend her knees, and the resident became tearful and said she had been hit. The facility’s abuse investigation was inconsistent and incomplete, with omitted written witness statements and a conclusion that the allegation was unsubstantiated despite accounts describing physical contact.
Failure to Prevent Retaliation Against Staff: The facility failed to prohibit and prevent retaliation after staff attempted to speak with surveyors and report concerns. Although the handbook and posted notice included anti-retaliation language, five terminated employees had personnel files that did not support the reasons given for termination, and the NHA cited vague reasons such as professionalism, job abandonment, refusal to complete an admission, aggression, and alleged inciting of a verbal riot. Confidential interviews described management questioning staff about speaking with the surveyor, threats of immediate termination for calling the state, and a climate of fear related to complaints about staffing and resident care.
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program and Resident-to-Resident Altercations policies when Resident 2, who had diagnoses including schizoaffective disorder and parkinsonism and was later placed on 72-hour monitoring for verbal aggression and spitting, was not adequately managed after an altercation with Resident 3. On 6/15/2026, Resident 2 was documented as being irritated, calling Resident 3 names, threatening to beat Resident 3 up, and spitting on Resident 3, with the spit landing on Resident 3’s shirt. The facility moved Resident 2 to another room, but the record showed the 72-hour monitoring documentation was incomplete, with no note covering the final 11 hours of the ordered monitoring period. The facility also failed to report and investigate the abuse allegations involving Resident 2 and Resident 3. During interview, the DON and LVN1 stated that spitting was not abuse and that there was no need to report the incident as abuse. The DON stated she did not report the incident to the Ombudsman, local police, or CDPH because spitting and name calling were not considered abuse. Later, LVN1 used a Google search and stated that spitting at another resident was considered physical abuse, and the DON stated the physical abuse between Resident 2 and Resident 3 should have been reported and investigated. The facility’s policy stated that all altercations, including those that may represent resident-to-resident abuse, were to be investigated and reported. The facility further failed to protect Resident 1, who was bedbound and dependent on staff for multiple activities of daily living, from physical abuse by Resident 2. On 6/18/2026, Resident 1 alleged that Resident 2 hit him on the head with an overhead table, causing a laceration and bleeding. Resident 1 was transferred by emergency services to a general acute care hospital and was diagnosed with blunt trauma, closed head injury, and scalp lacerations. The record also showed that Resident 2 had been moved into Resident 1’s room after the earlier altercation with Resident 3, and the DON did not respond when asked whether supervision had been provided to prevent Resident 2 from hitting Resident 1. The report also states that staff were not able to identify all types of abuse, and that Resident 1 and Resident 3 were not protected from abuse from Resident 2.
Failure to Complete Required Background Check Before Direct Care
Penalty
Summary
The facility failed to implement its abuse prevention program when CNA 1 did not have a completed background check before providing direct resident care. The DON stated CNA 1 was hired on January 30, 2026, began direct patient care on March 3, 2026, and graduated from the facility's CNA training program on March 31, 2026. The DON also stated that background checks were supposed to be completed before staff started work, but CNA 1's background check was not requested until June 19, 2026, and was not completed until July 7, 2026. During interview and record review, CNA 1's background check document, titled California Investigative Consumer Report, showed the delayed request and completion dates. The DON stated CNA 1 should have had the background check done in January 2026 and that a previous HR employee had been responsible for ensuring background checks were completed, but management identified that the employee was not doing them as required. A time card report showed CNA 1 worked 571.7 hours between March 3, 2026, and July 7, 2026, before the background check was completed. The facility policy stated it conducts employee background checks and will not knowingly employ individuals convicted of abusing, neglecting, or mistreating individuals.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy for allegations involving resident-to-staff and resident-to-resident abuse. The report states that the facility did not notify the appropriate State Agencies and did not thoroughly investigate allegations involving three residents. The deficiency was based on clinical record review, facility documentation, staff interviews, and policy review. For one resident, who had diagnoses including unspecified mood disorder, suicidal ideations, anxiety disorder, and depression, a nurse documented that the resident reported being in a physical altercation with a CNA and had visible scratches to the arms. The DON and NP were notified, and later documentation reflected conflicting accounts from the resident, including statements that the scratches were self-inflicted and that the resident had slapped and choked the CNA. The resident’s record showed a BIMS of 14 and behaviors including delusions, physical and verbal behavior, and rejection of care. Staff interviews reflected that the resident was known for making false accusations, and the Administrator stated the allegation was not considered reportable because the resident said she was the aggressor. The report also noted that the CNA involved continued to work shifts after the initial allegation and was not placed on administrative leave until several days later. For two other residents, one resident was found standing over the other while the other resident stated that the roommate had walked up and started hitting him. The record documented that the residents were separated, one resident was placed on 1:1, and the injured resident had a bruise and later a skin tear and discoloration on the left hand. The resident who was alleged to have caused the injury had diagnoses including anoxic brain damage, hydrocephalus, PTSD, major depressive disorder, unspecified dementia, and unspecified mood disorder, with a BIMS of 1 and documented physical behaviors and aggression. Staff interviews described the incident as resident-to-resident abuse, with one CNA stating the resident was over the other resident in bed and another stating the residents were fighting when staff arrived. However, the Administrator stated the event was not considered abuse because there was no willful intent and therefore was not reported. The facility policy required suspected abuse to be reported immediately to the administrator and other officials according to state law, with immediate defined as within 2 hours for allegations involving serious bodily injury or within 24 hours for allegations not involving serious bodily injury.
Failure to Investigate and Report Abuse-Related Allegations
Penalty
Summary
The facility failed to follow its abuse prevention policy for three residents with abuse-related concerns by not reporting, investigating, documenting, or following up on the allegations as required. The report states the facility had a policy prohibiting abuse, neglect, exploitation, mistreatment, and misappropriation of resident property, and that suspected abuse or mistreatment was to be immediately reported, residents protected from further possible abuse, and a prompt, thorough investigation completed and documented. For each of the three residents, the facility had knowledge of the concerns but did not provide documentation showing the allegations were reported to the State Agency, investigated, concluded, or reviewed for follow-up and corrective action. For one resident, staff reported that the resident had been called a racial slur by a roommate. The resident was moved to another room after administration became aware of the concern, but the record did not show the allegation was reported or investigated. The administrator and DON later confirmed the facility knew about the allegation and moved the resident, but also confirmed no abuse investigation was completed and the allegation was not reported to the State Agency. The facility did not provide documentation showing interviews, record review, protection measures, findings, a final decision, or action to prevent recurrence. For a second resident, concerns involved staff treatment, refusal or delay of help, dignity, and possible mistreatment. A CNA reported that the resident said another CNA called her lazy and that there were repeated arguments and issues with care. The resident stated the CNA was intimidating, argued with her, called her lazy, and made her feel bad about herself. The administrator stated he was aware of the situation and spoke with the CNA, but there was no investigation. The facility did not document that it reviewed the concern as possible mistreatment, neglect, retaliation, or degrading treatment, and did not document reporting determination, resident or staff interviews, witness interviews, record review, follow-up, findings, or a final decision. For a third resident, the allegation involved degrading staff conduct during wound care. A nurse reported that the resident was upset after a staff member said the bandages were gross and that she did not want to catch anything from the resident’s draining wounds. The resident stated the nurse had a disgusted look, sighed, and asked whether the wounds were contagious, which made the resident feel angry, degraded, awful, and fearful. The administrator stated there was no abuse investigation related to the incident. The facility did not provide documentation showing the allegation was reported to the State Agency, reviewed as possible abuse, neglect, or mistreatment, or investigated with resident, staff, or witness interviews, wound-care record review, follow-up, findings, or a final decision.
Abuse Allegation Not Thoroughly Investigated
Penalty
Summary
The facility failed to implement its abuse policy after an incident involving a staff member and Resident #96. Resident #96 was admitted with multiple diagnoses including palliative care, muscle spasms, atherosclerotic heart disease, cervical cancer, type 2 diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder. A Medicare 5-Day MDS showed a BIMS score of 11, indicating moderate cognitive impairment. During the incident, the resident was found slipping from her wheelchair with both knees locked and her body rigid while staff attempted to reposition her. The resident was repeatedly instructed to relax and bend her knees, and she was later assisted to bed for safety. The clinical record and investigation documents showed conflicting accounts of what occurred during the transfer. One staff witness reported that the LPN tapped or smacked the resident’s leg to get her to bend her knees, while the resident later told staff that the nurse hit her leg until it relaxed. Another staff member documented that the resident said the nurse was yelling and hitting her legs, and the resident became tearful and stated that the incident made her feel like no one cared about her and that she was not wanted at the facility. The resident’s family members also reported that they were told the nurse had hit or jabbed the resident’s leg during the transfer. The facility’s investigation was incomplete and inconsistent with its own policy. The investigation was initially determined to be unsubstantiated, with the conclusion that no policies were broken, despite witness statements and resident interviews describing physical contact to the resident’s leg during the transfer. The investigation also omitted written witness statements that were later requested and obtained, including statements from staff who reported that the resident said she had been hit and that the nurse had struck or smacked her leg. The facility policy required all allegations of abuse to be thoroughly investigated, including interviews with staff who had contact with the resident, witnesses, the reporting person, and the resident or representative, and required written, signed, and dated witness statements.
Failure to Prevent Retaliation Against Staff
Penalty
Summary
The facility failed to prohibit and prevent retaliation against employees after staff members made complaints and attempted to speak with the State Survey Agency. Review of the facility handbook showed anti-retaliation language and disciplinary procedures, and a posting in the staff lounge stated that an LTC facility cannot punish or retaliate against an employee for lawfully reporting a crime. Despite those policies, survey interviews and employee file review identified five terminated employees whose terminations were described by the Nursing Home Administrator as being for "professionalism," with additional explanations such as refusal to complete an admission, aggression toward the NHA, alleged inciting of a verbal riot, and job abandonment. The personnel records reviewed for the terminated employees did not contain documentation supporting the reasons given for the terminations. One employee had no disciplinary actions in the prior 12-month rolling calendar and a performance evaluation showing meets or exceeds expectations. Another had one attendance-related disciplinary action and performance evaluations showing meets or exceeds expectations. Two employees had no performance reviews or disciplinary actions documented, and another had no disciplinary actions with performance evaluations showing meets or exceeds expectations. The NHA confirmed that the files did not contain documentation of the behaviors cited as the basis for termination. During confidential staff interviews, multiple employees reported unsafe staffing, residents not receiving timely care, and fear of retaliation for speaking with surveyors or reporting concerns. One staff member stated the Interim DON called to ask why the staff member wanted to speak to the surveyor, and the staff member later reported being terminated by voicemail. Other staff reported being told that if they called the state they would be immediately terminated, that management knew who was calling the state, and that employees were being told to keep their mouths shut. On survey, the facility administration was made aware that the facility failed to prohibit and prevent retaliation for five of fifteen staff members.
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